Step 3 Exam Overview

The USMLE Step 3 exam consists of multiple choice and computer-based simulations to assess a medical student or graduate’s application of their medical knowledge and understanding of biomedical and clinical science in managing patients in an unsupervised setting. The results of this exam demonstrate their ability to independently provide a standard of care to their patients. Step 3 is the final component of the USMLE exam series.

Examination Content

The Step 3 examination is organized in three dimensions:

  • Normal conditions and disease categories (normal growth and development, basic concepts, and general principles)
  • Clinical encounter frame (initial workup, continuing care, urgent intervention)
  • Physician task (applying scientific concepts, formulating a diagnosis based on history, physical examination, and laboratory findings, and managing the patient)

Clinical encounter frames are common clinical scenarios physicians may encounter. They range from nonemergency problems, through continuity of care, to life-threatening emergency situations encountered in emergency departments, clinics, offices, care facilities, inpatient settings, and on the telephone. Each test item in an encounter frame represents one of the six physician tasks. For example, initial care encounters emphasize taking a history and performing a physical examination. In contrast, continued care encounters emphasize decisions regarding prognosis and management.

Test Length and Format

Step 3 is a two-day examination and uses two formats: multiple choice questions and Primum computer-based case simulations (CCS), a testing format that allows you to provide care for a simulated patient.

Day one of testing includes 233 multiple-choice items divided into 6 blocks of 38 to 40 items; 60 minutes are allotted for completion of each block with 7 hours of total test session including 45 minutes of break time and a 5-minute optional tutorial. Day two of testing includes 180 multiple-choice items, divided into 6 blocks of 30 items; 45 minutes are allotted for completion of each block. Day two also includes thirteen computer-based case simulations (CCS), each of which is allotted 10 or 20 minutes of maximum real time. A total of 9 hours is allocated for test session on the second day.

Step 3 case simulations must be taken in the order presented. After you exit the case or session or when time expires, you can no longer review test items or cases, change answers, or collect additional information.

Eligibility Criteria

To be eligible for Step 3, prior to submitting your application, you must:

  • Obtain the MD degree (or its equivalent) or the DO degree
  • Pass Step 1, Step 2 CK, and, if required based upon the rules referenced below, Step 2 CS
  • Obtain certification by the ECFMG or successfully complete a Fifth Pathway program if you are a graduate of a medical school outside the United States and Canada (information on Fifth Pathway programs is available in ECFMG’s Information Booklet)
  • Meet the Step 3 requirements set by the medical licensing authority to which you are applying

When should I take Step 3?

In contrast to Steps 1 and 2 of the USMLE, it is required that Step 3 be taken after completion of medical school, generally during residency. The timing of when during residency to take the test varies from student to student. Some may wish to take the exam earlier in training in order to have the licensing process completed, which may open up opportunities for moonlighting, etc. Other students may wish to delay the examination due to financial considerations or a desire to focus on their new specialty field.

A 2003 study examined the impact that both postgraduate training and timing had on Step 3 performance. Results were controlled for students' performance on the Step 1 and 2 exams. The study found that graduates whose postgraduate training focused on broad areas performed better than those with more specialized training, with those residents studying either med-peds or family practice performing the best on the exam relative to earlier USMLE performance. Residents from fields such as emergency medicine, internal medicine, and pediatrics also performed well. These results are not surprising given the generalist-oriented nature of Step 3. Among residents from these general fields, performance improved with increased postgraduate training. However, performance on the exam was still less than what would be expected based on Step 1 and 2 results. (Only the med-peds and family practice residents with over a year of postgraduate training performed better than expected.) This may be due, at least in part, to the fact that many residents study less for Step 3 than they did for Steps 1 and 2. These findings suggest that residents from more generalized training programs may perform better if they take the exam later in their training.

The study had somewhat different findings for students in more specialized postgraduate training. Residents from the fields of anesthesiology, psychiatry, radiology, pathology, surgery, and Ob/Gyn all performed relatively poorly in relation to what their earlier scores might have predicted, compared to residents in more general specialties. Contrary to what might be expected, a delay in taking the exam did not impact scores negatively. It is unclear if this reflects a trend for residents taking the exam later to have studied longer.


Sawhill AJ, Dillon GF, Ripkey DR, Hawkins RE, Swanson DB. The Impact of Postgraduate Training and Timing on USMLE Step 3 Performance. Academic Medicine , 78 (10), October Supplement 2003, S10-S12.

Why should I care about my Step 3 score since I am already in residency?

The USMLE exams are designed to assess one's competency to practice medicine. Step 3 is the last in the series of tests, and passing it is required to obtain a medical license. Although not designed for this purpose, both Step 1 and Step 2 are heavily weighted in the resident selection process. In contrast, Step 3, typically taken during or after the first year of residency, is not used in resident selection. While it is important to pass the exam, most fellowship directors and eventual employers do not place much emphasis on the raw score. If released, scores from the USMLE Step 3 exam are sent back to the resident's original medical school, which helps the medical school make judgments about certain elements of the curriculum.

Step 3 is even more clinically relevant than Step 2, testing more complex concepts with an emphasis on patient management and prognosis. The Step 3 exam has a computerized patient simulation section in addition to the standard multiple choice section during which the student must order the appropriate tests and administer the correct treatments for a given patient, with changes in the patient's status based on the examinee's actions. This interactive format is meant to mimic actual clinical situations.

Studying for Step 3 gives the resident the opportunity to synthesize information learned across different subspecialties. The Step 3 score report also provides feedback that breaks down the examinee's performance by subspecialty; this may help the resident identify areas of weakness. This is particularly helpful for residents in fields such as family medicine, in which all the tested areas will likely be part of their future clinical practice.


Andriole DA, DB Jeffe, Hageman HL, Whelan AJ. What Predicts USMLE Step 3 Performance? Academic Medicine. 80 (10), October 2005 Supplement, S21-S24.